Integrated Care For Patients Research Articles

A nurse-led intervention improves quality of life and reduces arrhythmic recurrences in patients undergoing atrial fibrillation ablation. Results of the NURSECAT-AF randomized clinical trial

Abstract Background/Introduction Atrial fibrillation (AF) is a prevalent condition that can lead to a decrease in quality of life and frequent re-hospitalizations. Some data suggest that integrated care nurse-led may blunt these consequences in unselected patients with AF, but not all studies support this. While AF ablation is becoming a cornerstone treatment for symptomatic patients with AF, it is unclear what impact a nurse-led intervention would have on these, quite likely, more receptive patients. Purpose To assess the impact of nurse-led intervention on quality of life among AF patients undergoing ablation. Methods We conducted a single-centre prospective randomised clinical trial to test the effect of an expert nurse-based intervention consisting of an educational programme on AF, support for the patient undergoing cardiac ablation to ensure its success, and management of risk factors associated with this arrhythmia. The control group underwent standard medical follow-up. Patient selection was based on chronological order. Only patients who underwent their first ablation and did not have heart failure were included. The primary endpoint was quality of life at 12 months post-ablation using the Arrhythmia-Specific Scale in Tachycardia and Arrhythmia (ASTA) questionnaire (higher values denote impaired quality of life). Secondary endpoints were AF knowledge and satisfaction at 15 days post-ablation using validated instruments, symptoms using the ASTA questionnaire as well, and readmissions rates, emergency room visits, and AF recurrence rates over a one-year period. Results 116 patients were screened (50 were excluded mostly because were re do). A total of 66 patients were eventually included and randomized (33 per arm; mean age [mean±SD] 63±10 years; 44 men [67%]). At 12 months, quality of life was significantly better in the intervention group than in the control group (4.5 ± 6.1 vs 0.57 ± 2.3, respectively, p=0.001)(Figure). Furthermore, satisfaction levels (17 ± 4.1 vs 12.7 ± 5.4, p>0.001) and disease knowledge (20.5 ± 5.1 vs 15.9 ± 4.5, p<0.001) were higher in the intervention group. Patients in the control group experienced a higher symptom burden during the first year (0.6 ± 1.5 vs 3.8 ± 4.5, p<0.001. Relevant clinical endpoints such as readmissions (3% vs 18.2%, p=0.046), emergency room visits (21.2% vs 57.5%, p=0.021), and arrhythmia recurrences (15.2% vs 45.5%, p=0.02) were all significantly lower in the intervention group. Conclusion(s) Nurse-led integrated care for patients undergoing AF ablation yields substantial improvements in quality of life and symptomatic relief at one year post-procedure. Additionally, it enhances patient knowledge of AF and satisfaction levels, and reduces readmissions, emergency room visits, and arrhythmia recurrences.

Early detection of liver disease in patients with alcohol use disorder improves long-term abstinence.

Excessive alcohol consumption is a major global health concern, contributing to millions of deaths annually and a significant proportion of cirrhosis cases; however, standardized protocols for early identification of alcohol-associated liver disease are lacking. In this retrospective cohort study, we aimed to understand the prevalence and risk factors associated with elevated liver stiffness measurement (LSM) in high-risk patients with alcohol use disorder (AUD) and identify variables associated with longitudinal abstinence and outcomes. Veterans with severe AUD without known liver disease admitted to a 35-day residential substance use treatment program were offered liver health screening, including Fibroscan evaluation. Assessment of AUD severity and liver health outcomes were evaluated longitudinally by chart review. In a cohort of 257 veterans with severe AUD admitted to residential treatment, 185 underwent Fibroscan evaluation, and 22 were identified to have elevated LSM concerning for compensated advanced chronic liver disease. Patients with elevated LSM were more likely to remain abstinent after 1 year. About 41% of patients with LSM ≥ 10kPa (5% of all screened patients) were confirmed to have cirrhosis on follow-up and incorporated into routine hepatology care. Screening of liver disease in high-risk populations with non-invasive imaging modalities provides an opportunity to identify patients at risk for compensated advanced chronic liver disease before decompensation. Identification of increased risk for advanced chronic liver disease may promote abstinence in patients with severe AUD. Collaboration between mental health professionals and hepatologists is critical for the integration of care for patients with AUD and liver disease.

Associations Between Telemedicine Use Barriers, Organizational Factors, and Physician Perceptions of Care Quality.

Introduction: Evaluating physician perceptions of telemedicine use and its impact on care quality among physician providers is critical to sustaining telemedicine programs, given the uncertainty of reimbursement policy, preferences, inadequate training, and technical difficulties. Physicians reported technical barriers to effectively practicing integrated medicine using telemedicine as patient volumes increased during the pandemic. The objective of this work was to examine whether perceived practice barriers and facilitators were associated with physician respondents' perceptions of telemedicine care quality compared with in-person care. Methods: This cross-sectional study analyzed the 2021 National Electronic Health Record Survey. The sample comprised 1,857 nonfederally employed physicians (weighted n = 403,013) delivering integrated patient care. Of those physicians, 1,630 (weighted n = 346,646) reported providing care through telemedicine. We reported frequencies and percentages of reported practice characteristics. Generalized ordinal logistic regressions examined relationships between practice factors and care quality for telemedicine care. Results: Most of the sample (n = 1,630) were male (66.1%), >50 years of age (66.1%), and worked in a single location (73.5%). A total of 70% of respondents reported that patients had difficulty using telemedicine platforms, and 64% reported limitations in patients' access to technology. Most respondents indicated having provided quality care to some extent (45%) and to a great extent (26%) during telemedicine visits compared to in-person visits. Associations between barriers, facilitators, and care quality perceptions were positive, underscoring resiliency in telemedicine programs among practices. Conclusion: Care modalities and the organizational, environmental, and personal facilitators drive quality perceptions among physicians. Perceived fit and usability determine perceptions of care quality for providers integrating telemedicine into their practice.

Implementation of the use of active methodologies used by preceptors of the pain outpatient clinic of the University Hospital of the Federal University of Juiz de Fora: Experience report

Introduction: The Multiprofessional Pain Outpatient Clinic (AMD) was created at the University Hospital of the Federal University of Juiz de Fora (HU-UFJF) to offer an integrated and interprofessional approach to the treatment of chronic pain, in line with the Multiprofessional Residency in Adult Health. To face the complex demands of AMD and promote more engaged and meaningful learning, the need arose to use Active Methodologies (AM) in the teaching-learning process of residents. Objective: To report the creation of a preceptorship plan for the implementation of active methodologies in the teaching-learning process of AMD, with the objective of developing critical, communication and teamwork skills in health professionals and promoting more effective and integrated care for patients with chronic pain. Experience Report: The study adopted the format of an experience report and took place at AMD, involving an interprofessional team composed of residents and preceptors. Several active methodologies were used, such as case studies, problem-based learning, interprofessional teaching, experiential learning, among others. The implementation of active methodologies in AMD demonstrated significant potentialities, including improvements in resident performance, development of communication and teamwork skills, favoring interdisciplinary practices, and academia-service integration. A more active and engaged participation of students in the discussions of clinical cases was observed, resulting in a deeper understanding of the clinical concepts presented. Conclusion: Active methodologies represent an effective strategy to promote learning and professional development in AMD, contributing to a more integrated and efficient care for patients with chronic pain. The study highlights the importance of continuous training of health professionals and the search for innovative practices in the context of chronic pain.

M130 - Successful Integration of Care for Patients With Serious Injection-Related Infections and Substance Use Disorder in a Tertiary Care Hospital.

M130 - Successful Integration of Care for Patients With Serious Injection-Related Infections and Substance Use Disorder in a Tertiary Care Hospital.

Patient and Provider Attitudes and Preferences Regarding Early Palliative Care Delivery for Patients with Advanced Gastrointestinal Cancers: A Prospective Survey.

Early integrated palliative care (EIPC) for patients with advanced cancers requires the involvement of family doctors (FDs) and oncologists. We compared attitudes between patients and their providers regarding the delivery of EIPC. Patients with newly diagnosed incurable gastrointestinal (GI) cancer at a tertiary cancer centre in Ontario, Canada, were surveyed using a study-specific instrument regarding the importance of and preferences for accessing support across eight domains of palliative care. Physicians within the circle of care completed a parallel survey for each patient. The concordance between patient and physician responses was analyzed. A total of 66 patients were surveyed (median age 69, 35% female). All had an oncologist, 12% had a specialist palliative care provider (SPC), and 97% had an FD, but only 41% listed the FD as part of the care team. In total, 95 providers responded (oncologist = 68, FD = 21, SPC = 6; response rate 92%; 1-3 physician responses per patient). Disease management and physical concerns were most important to patients. Patients preferred to access care in these domains from oncologists or SPCs. For all other domains, most patients attributed primary responsibility to self or family rather than any healthcare provider. Thus, concordance was poor between patient and physician responses. Across most domains of palliative care, we found low agreement between cancer patients and their physicians regarding responsibilities for care, with FDs appearing to have limited involvement at this stage.

A call for action to include psychosocial management into holistic, integrated care for patients with atrial fibrillation.

Contemporary management of atrial fibrillation (AF) has become increasingly complex. Therefore, strong efforts have been made during the past decade to develop models for structured, integrated care for patients with AF. These have also been incorporated in international guidelines for the management of patients with AF. However, implementation of integrated care approaches in daily clinical practice is scarce and far from optimal, and it may require a re-thinking of the structure of the healthcare system. The reasons for the poor implementation are many, from limited time and economic resources to deficits in postgraduate education of healthcare professionals, lack of involvement of patients in how integrated care should be designed, and fragmentation of the healthcare system. Moreover, patients' psychological challenges, which not only impact patients' adherence to treatment but, if untreated, increase their risk of morbidity, mortality, and poor quality of life, are not given sufficient attention. It is time to start a necessary discussion of what integrated care should be, what it should contain, and what is necessary to implement it in daily clinical practice.

Cardiogenic shock and chronic kidney disease: Dangerous liaisons

BackgroundChronic kidney disease (CKD) is one of the leading causes of death worldwide, closely interrelated with cardiovascular diseases, ultimately leading to the failure of both organs – the so-called “cardiorenal syndrome”. Despite this burden, data related to cardiogenic shock outcomes in CKD patients are scarce. MethodsFRENSHOCK (NCT02703038) was a prospective registry involving 772 patients with cardiogenic shock from 49 centres. One-year outcomes (rehospitalization, death, heart transplantation, ventricular assist device) were analysed according to history of CKD at admission and were adjusted on independent predictive factors. ResultsCKD was present in 164 of 771 patients (21.3%) with cardiogenic shock; these patients were older (72.7 vs. 63.9years) and had more comorbidities than those without CKD. CKD was associated with a higher rate of all-cause mortality at 1month (36.6% vs. 23.2%; hazard ratio 1.39, 95% confidence interval 1.01–1.9; P=0.04) and 1year (62.8% vs. 40.5%, hazard ratio 1.39, 95% confidence interval 1.09–1.77; P<0.01). Patients with CKD were less likely to be treated with norepinephrine/epinephrine or undergo invasive ventilation or receive mechanical circulatory support, but were more likely to receive renal replacement therapy (RRT). RRT was associated with a higher risk of all-cause death at 1month and 1year regardless of baseline CKD status. ConclusionsCardiogenic shock and CKD are frequent “cross-talking” conditions with limited therapeutic options, resulting in higher rates of death at 1month and 1year. RRT is a strong predictor of death, regardless of preexisting CKD. Multidisciplinary teams involving cardiac and kidney physicians are required to provide integrated care for patients with failure of both organs.

Needs analysis for an undergraduate dental curriculum in KPK, Pakistan: Gap identification and general needs assessment.

Dental institutes continue to face challenges in making the transition from a discipline-based to an integrated curriculum. The need analysis is often the first step in the development and implementation of any curriculum. This study intends to carry out a needs analysis for a contemporary dental curriculum in private and public sector dental colleges of Peshawar, KPK, Pakistan. The mixed method study was carried out at public and private dental institutes in Peshawar from April to July 2022. To guarantee triangulation, data were gathered from three sources. The first source was an analysis of the Pakistan Medical and Dental Council's dental curriculum accreditation standards. The second source was gathering the experts' perspectives, and the final source was a systematic literature search to explore the necessity for an integrated undergraduate dental curriculum from the experiences and expertise of contemporary curricula. Thematic analysis identified the need for the dental curriculum to be a five-year BDS program, involvement of students, and inclusion of digital dentistry and environmental sustainability in the dental curriculum. PMDC accreditation standards focus on alignment in mission, vision, curricular outcomes, an integrated curriculum, and a quality assurance system for assessment. Experts identified the need for a patient-centered curriculum focusing on integrated patient care. They also identified that the current educational environment should be improved to sustain a contemporary dental curriculum in Pakistan. For the literature review, nine articles were included in the final review. The current dental curriculum is not accommodating to the needs of the students in Peshawar. The current dental education environment lacks the infrastructure, logistics, and teacher training to sustain the standards set by PMDC.

Risk factors for pulmonary tuberculosis recurrence, relapse and reinfection: a systematic review and meta-analysis

BackgroundThe rate of pulmonary tuberculosis (TB) recurrence is substantial. Identifying risk factors can support the development of prevention strategies.MethodsWe retrieved studies published between 1 January 1980 and 31 December 2022...

Educational training in disease management for persons providing peer support to patients with type 2 diabetes and arterial hypertension at the primary healthcare level.

Introduction: Good metabolic control of a patient with type 2 diabetes (T2D) and arterial hypertension (AH) requires continuous monitoring of patient's health and associated diseases, where lifelong education and support represent key factors in patient empowerment and successful self-management. This is a task beyond the capabilities of healthcare professionals in Slovenia, which could be solved with engagement and cooperation of partners outside the healthcare system. Therefore, appropriate organisation, training and functioning of lay persons, who will provide peer support, can significantly contribute to improved integrated care in patients with T2D and AH. In this way trained peer supporters will voluntarily share their knowledge, experiences and support to other patients with the same chronic disease without linguistic nor cultural barriers.&#x0D; Aim: The aim of our pilot study was to determine the acceptability, effectiveness and feasibility of educational training in disease management for persons providing peer support to patients with T2D and AH at the primary healthcare level in Slovenia. &#x0D; Methods: This study is a part of an ongoing international research project SCUBY (SCale Up diaBetes and hYpertension care). Our pilot study started with recruitment of 36 patients with T2D and/or AH. Participants were educated in a total of 15 hours of group and individual training by nurses with special skills. Before and after completing the training, participants filled out questionnaires including sociodemographic and clinical data, knowledge about T2D and AH, Appraisal of Diabetes Scale and Theoretical Framework of Acceptability.&#x0D; Results: 31 patients (21 women and 10 men) successfully completed structured educational training in management of their T2D and AH and became trained peer supporters. Their average age was 63,9 ± 8,9 years, they were treated for T2D on average of 14,3 ± 11,7 years and for AH on average of 7,9 ± 8,1 years. Compared to the knowledge at the time of entering the research, their knowledge about T2D (p&lt;0,001) as well as about AH (p=0,022) increased significantly. The impact on the quality of life with T2D was insignificantly better (p=0,146). The participants rated training as highly acceptable in all 7 domains of acceptability; the total mean score on a 5-point scale was 4,44 ± 0,52. &#x0D; Conclusions: Educational training in disease management for peer supporters proved to be highly acceptable, effective and feasible, which indicates a great potential for successful implementation of peer support for patients with T2D and AH at the primary healthcare level in Slovenia. Active role of trained peer supporters will lead to the development of a new form of cooperation and collaboration between patients, their family members, informal caregivers in local community and healthcare professionals.

Community-based integrated care for patients with diabetes and depression (CIC-PDD): study protocol for a cluster randomized controlled trial

BackgroundManaging the multimorbidity of diabetes and depression remains a clinical challenge for patients and healthcare professionals due to the fragmented healthcare delivery system. To effectively cope with multimorbidity, there is an urgent need for the health system to transform into people-centered integrated care (PCIC) system globally. Therefore, this paper describes the protocol of community-based integrated care for patients with diabetes and depression (CIC-PDD) project, an integrated and shared-care intervention project.Methods/designCIC-PDD project is conducted in two phases, namely “care model development” and “implementation and evaluation.” In the first phase, CIC-PDD model was designed and developed based on the four criteria of collaborative care model (CCM) and was subsequently adjusted to align with the context of China. The second phase entails a pragmatic, two-arm, cluster randomized controlled implementation trial, accompanied by parallel mixed-methods process evaluation and cost-effectiveness analysis.DiscussionWe anticipate CIC-PDD project will facilitate the development and innovation of PCIC model and related theories worldwide, particularly in low- and middle-income countries (LMICs). In addition, CIC-PDD project will contribute to the exploration of primary health care (PHC) in addressing the multimorbidity of physical and mental health issues.Trial registrationClinicalTrials.gov registration ChiCTR2200065608 (China Clinical Trials Registry https://www.chictr.org.cn). Registered on November 9, 2022.

Managing the Increasing Burden of Atrial Fibrillation through Integrated Care in Primary Care: A Cost-Effectiveness Analysis.

Integrated care for patients with atrial fibrillation (AF) in primary care reduced mortality compared to usual care. We assessed the cost-effectiveness of this approach. Dutch primary care practices were randomised to provide integrated care for AF patients or usual care. A cost-effectiveness analysis was performed from a societal perspective with a 2-year time horizon to estimate incremental costs and Quality Adjusted Life Years (QALYs). A sensitivity analysis was performed, imputing missing questionnaires for a large group of usual care patients. 522 patients from 15 intervention practices were compared to 425 patients from 11 usual care practices. No effect on QALYs was seen, while mean costs indicated a cost reduction between €865 (95% percentile interval (PI) -€5730 to €3641) and €1343 (95% PI -€6534 to €3109) per patient per 2 years. The cost-effectiveness probability ranged between 36% and 54%. In the sensitivity analysis, this increased to 95%-99%. Results should be interpreted with caution due to missing information for a large proportion of usual care patients. The higher costs from extra primary care consultations were likely outweighed by cost reductions for other resources, yet this study doesn't give sufficient clarity on the cost-effectiveness of integrated AF care.

Análisis de interacciones de actores de la red de gestión del conocimiento en malaria de Colombia

Analizar las interacciones de la Red de Gestión del Conocimiento, Investigación e Innovación en Malaria de Colombia. Materiales y métodos. Se hizo un análisis de redes sociales que permitió identificar la proximidad entre los actores y el grado de conocimiento entre ellos; se observaron indicadores de densidad, diámetro, distancia media y centralidad de grado. El corpus documental para el estudio estuvo constituido por 193 documentos técnicos publicados entre el 2016 y el 2021, que fueron analizados empleando técnicas de procesamiento de texto mediante el lenguaje de programación R. La categorización de la red se realizó a partir de cinco variables: atención integral a pacientes, diagnóstico, epidemiología y sistemas de análisis de información en salud, política pública, y promoción y prevención. El análisis de las interacciones indicó que la red la conformaban 99 actores, de los cuales 97 (98 %), mostraron más interés en la producción de conocimientos en epidemiología y sistemas de análisis de información en salud, seguido de la categoría de atención integral a pacientes con 79 (80 %). El 54 % de los actores llevó a cabo estudios de promoción y prevención, siendo esta la categoría de menor abordaje. Este estudio contribuye al fortalecimiento de estrategias clave en la divulgación del conocimiento sobre la malaria en Colombia.

Integrated care for patients with multimorbidity: co-production of the Primary Organization- and Relations Team

The International Journal of Integrated Care (IJIC) is an online, open-access, peer-reviewed scientific journal that publishes original articles in the field of integrated care on a continuous basis.IJIC has an Impact Factor of 2.913 (2021 JCR, received in June 2022)The IJIC 20th Anniversary Issue was published in 2021.

A synergistic impact of early rhythm control and lifestyle modification on the risk of stroke in patients with new-onset atrial fibrillation: a Korean nationwide population-based cohort study

Abstract Background Early rhythm control therapy and lifestyle modification have both been associated with a lower risk of stroke in patients with atrial fibrillation (AF). Although guidelines have emphasized integrated care for patients with AF to improve clinical outcomes, the synergistic impact of early rhythm control therapy and lifestyle modification on the risk of stroke is unclear. Purpose To evaluate the impact of the combination of early rhythm control therapy and lifestyle modification on the risk of stroke Methods Based on data from the Korean National Health Insurance Service database, we included patients with new-onset AF between January 2009 and December 2016. Based on questionnaires from health checks, patients with ≥2 healthy lifestyle behaviors among quitting smoking, abstaining from alcohol, and performing regular exercise were defined as “healthy lifestyle” group. Patients who received rhythm control therapy within 2-year after new-onset AF were defined as the early rhythm control group. With a two-by-two factorial design, patients were categorized into 4 groups as follows: (i) those without early rhythm control and healthy lifestyle (group 1); (ii) those with a healthy lifestyle but without early rhythm control (group 2); (iii) those with early rhythm control but without healthy lifestyle (group 3); and (iv) those with both early rhythm control and healthy lifestyle (group 4). The primary outcome was stroke. Results Among a total of 208,662 patients, 46,972, 110,479, 15,133, and 36,078 patients were included in group 1, 2, 3, and 4, respectively. For the early rhythm control group, the mean duration from AF diagnosis to rhythm control therapy was 27±76 days. During a median follow-up of 4.2 years, 9905 patients had an incident stroke (incidence rate, 10.6 per 100 person-years). After multivariable adjustment, compared to group 1, group 2 (healthy lifestyle only) and group 3 (early rhythm control only) were associated with a lower risk of stroke (HR and 95% CI: 0.769, 0.728–0.881, and 0.774, 0.703–0.852, respectively) (Figure 1). Group 4 with early rhythm control and a healthy lifestyle had the lowest risk of stroke among all groups (HR 0.575, 95% CI 0.536–0.617 compared to group 1) (Figure 1). After propensity score (PS) weighting for group 2 and 4, additional early rhythm control based on healthy lifestyle was associated with a lowered risk of stroke by 22% (Figure 2). After PS weighting between groups 3 and 4, additional lifestyle modification based on early rhythm control was associated with a lowered risk of stroke by 27% (Figure 2). Conclusion In this large-scale observational cohort study, early rhythm control therapy and healthy lifestyle behavior might reduce the risk of stroke in patients with new-onset AF, consistent with the results from recent randomized clinical trials. Furthermore, implementing both early rhythm control therapy and a healthy lifestyle could synergize stroke prevention in these populations. Funding Acknowledgement Type of funding sources: None.

Post-COVID-19 Syndrome

Although acute COVID-19 usually lasts for 12 weeks from the onset of symptoms, some patients experience variable persistent symptoms. Post-COVID-19 syndrome is defined as persistent symptoms and/or long-term complications that appear during or after COVID-19, persist for more than 12 weeks, and cannot be explained by an alternative diagnosis. The common symptoms of post-COVID-19 syndrome include general, pulmonary, hematological, cardiovascular, neuropsychiatric, renal, endocrine, gastroenterological, and dermatological symptoms. As the natural course and pathophysiology of COVID-19 are not yet clear, close monitoring is needed for various sequelae in multiple organs that occur in post-COVID-19 syndrome. In particular, patients who have been hospitalized in the intensive care unit or who have recovered from severe COVID-19 require close monitoring for the development of post-COVID-19 syndrome. Multidisciplinary collaboration is essential to provide integrated outpatient care for patients with post-COVID-19 syndrome.

Perioperative medicine

Perioperative medicine delivers patient-centred, multidisciplinary, integrated care for patients from the contemplation of surgery throughout the surgical pathway to recovery. High-quality perioperative care reduces complications, improves outcomes, and leads to improved patient satisfaction and reduced healthcare costs. This article is based on key findings and recommendations from the Getting It Right First Time (GIRFT) national report on perioperative medicine and outlines key concepts of perioperative medicine; exploring how practice can be transformed to improve care. The GIRFT report was produced using information gathered from 72 visits and 119 surveys from NHS trusts in England. It illustrates examples of exemplary perioperative care across the country but also describes variation in access to and provision of perioperative care. To address this unwarranted variation and to tackle the implementation gap, transformation of perioperative care pathways ensuring a patient-centered approach, multi-professional collaboration and widespread adoption of best practice will be required.

Use of Care Bundles to Prevent Healthcare-Associated Infections in Intensive Care Units: Nurses' Views

Objective: The purpose of this study was to determine the views of nurses working in intensive care units regarding the use of care bundles in preventing healthcare-associated infections. Methods: This study used the focus-group interview method, which is one of the qualitative methods. Two focus-group interviews, each lasting about half an hour, were conducted with 14 intensive care unit nurses. Qualitative data obtained from the interviews were recorded on tape and in note form. The interviews were then transcribed and analyzed. The transcribed data from the focus-group discussions were grouped by theme and concept, and the statements of the participants were coded numerically according to these groupings. Three themes and six subthemes emerged in analyzing the qualitative data. Results: The nurses defined care bundles as "materials that provide integrated care for patients". They also stated that their benefits included providing a tool for self-monitoring, support and guidance for both patients and nurses. When whether they had experienced any difficulties while using care bundles, they stated that they had not experienced any. Furthermore, nurses stated that care bundles improved their perspectives, and that they were must-have items in intensive care units providing reminders rather than a waste of time. Conclusion: It is that the participation of nurses is important so that care bundles are used more widespread in order to prevent healthcare-associated infections in intensive care units.

Increased Opioid Consumption following DIEP Flap Breast Reconstruction: Effect of Depression and Anxiety.

Enhanced Recovery After Surgery (ERAS) protocols have decreased postoperative opioid consumption and hospital length of stay in deep inferior epigastric perforator (DIEP) flap breast reconstruction. We aim to evaluate whether there needs to be further adjustments to best improve outcomes specifically in patients with a preexisting psychiatric condition. A retrospective review was performed of all patients that underwent DIEP flap breast reconstruction between October 2018 and September 2020. This includes all patients with the most recent ERAS protocol implementation of intraoperative transverse abdominal plane blocks with liposomal bupivacaine. We looked at patients with a psychiatric diagnosis at the time of surgery. Specifically, forms of depression and anxiety were the psychiatric diagnoses for these patients. We divided these patients into three groups: those with no diagnoses, those with a single diagnosis, and those with both diagnoses. Primary outcomes observed were postoperative opioid consumption and length of stay. A one-way analysis of variance determined whether there was a difference between the three groups and a Tukey post hoc analysis made pairwise comparisons. A p-value of < 0.05 was significant. A total of 176 patients were analyzed in this study: 59 (33.5%) of our study population had a diagnosis of either depression, anxiety, or both. Postoperative opioid consumption was higher in patients with a psychiatric diagnosis compared with those without (123.8 to 91.5; p < 0.0005). A multiple regression model consisting of operating time, hospital length of stay, whether the patient has a psychiatric diagnosis, and history of chemotherapy statistically significantly predicted opioid consumption (p < 0.0005). With similar hospital length of stay postoperatively, it is notable that patients with a psychiatric diagnosis had significantly higher amounts of postoperative opioid consumption. This study highlights the need to further improve multidisciplinary integrated care for patients with psychiatric comorbidities to improve pain management postoperatively.